Getting the runaround on long-term care insurance

An insurance company relies on corporate gibberish to build a smoke screen around a denial of benefits.

About 70% of people over age 65 will require long-term care services during… (Joe Raedle, Getty Images )

Rita Corwin, 90, conscientiously paid her premiums for long-term care insurance for 21 years to make sure that if she needed help as she grew older and more fragile, she'd get it.

Yet now that she finds herself in a position to require such assistance, her insurer, Washington National Insurance Co., is denying her claims.

"She bought this insurance for the same reason anyone would," said Corwin's daughter, Leni, who has been representing her mother in their dealings with the company. "If you become disabled or need long-term care, it's just too expensive to pay for on your own."

As the baby boomers enter their sunset years, long-term care coverage represents an increasingly costly gamble for insurers. That's why Prudential stopped selling individual policies in March. MetLife exited the business in 2010.

About 70% of people over age 65 will require long-term care services during their lifetime, and more than 40% will need care in a nursing home, according to the U.S. Department of Health and Human Services.

Long-term care insurance sold today can run as much as 17% more than just a year ago, according to the American Assn. for Long-Term Care Insurance, an industry group. Double-digit annual rate hikes have become routine for many policies.

Not surprisingly, some insurers have become more aggressive in denying claims.

Corwin, of Altadena, fractured her hip in a fall in October 2011. A hip replacement followed. And when it became clear that she'd need a caregiver to help her, Washington National made good on her policy and covered $150,000 worth of assistance, which lasted about a year.

In August, Corwin experienced pain in her neck and shoulder. Her doctor diagnosed the problem as severe cervical spondylosis, which the U.S. National Library of Medicine defines as "a disorder in which there is abnormal wear on the cartilage and bones of the neck" and "a common cause of chronic neck pain."

The doctor, James Shankwiler, said in a September letter to Corwin's insurer that her condition "predisposes her towards prolonged disability and limitation," making her "a candidate for long-term assistance and home health to allow her appropriate care and treatment."

But a month later, Washington National contacted Corwin's daughter to say that it wouldn't cover additional service by a caregiver.

The insurer based its decision on the fact that six months hadn't elapsed since treatment ended this year for the fractured hip.

It noted that Corwin's policy specifies that at least half a year of "normal daily living" must pass before a claim can be made for "the same or related cause."

Corwin's daughter appealed the decision, pointing out that the new claim wasn't for the same or related cause. It was for an entirely different cause with an entirely different medical diagnosis.

Corwin, don't forget, is 90. Stuff happens.

Also don't forget: She's paid nearly $38,000 in premiums to Washington National over two decades to safeguard against stuff happening.

But the insurer last month denied Corwin's appeal without even addressing the key issue — that the latest claim was for a different cause than the previous one.

"Successive confinement due to the same or related cause not separated by at least six months of normal daily living will be considered the same occurrence," the company concluded.

"The whole crux of the matter is that this is a different occurrence," Leni Corwin told me. "But they're not even considering that."

She said she was told by a Washington National service rep that the company's decision was final, so no further appeals would be considered.

I got in touch with Barbara Ciesemier, a Washington National spokeswoman. She declined to delve into details of Corwin's case, but she said by email that the insurer "acted in accordance with policy provisions."

"It is our objective to pay all claims in a timely manner, consistent with the terms and conditions of our policies," Ciesemier said.

She said approval of claims "is not triggered by a medical diagnosis, but determined by the care that is required due to that sickness or injury."

"These policies have a maximum benefit limit per occurrence or period of care," Ciesemier continued. "Once the per-occurrence maximum has been reached, no additional benefits are payable unless the insured qualifies for a new occurrence."

This is the same brick wall Corwin ran into. Washington National isn't acknowledging that the two claims resulted from two different medical problems.

Moreover, Ciesemier seems to be saying that the doctor's diagnosis wasn't even a factor in denying the claim. Rather, the insurer focused solely on the fact that the services of a caregiver were once again required.

Ciesemier's insistence that Washington National "acted in accordance with policy provisions" is belied by its own policy language, which states that a single "occurrence" is defined as being "due to the same or related cause."